Gastrointestinal Issues in the Cardiothoracic ICU

Gastrointestinal Issues in the Cardiothoracic ICU

Carrie Harvey (University of Michigan Health System, USA), Katherine Klein (University of Michigan Health System, USA) and Michael Maile (University of Michigan Health System, USA)
Copyright: © 2015 |Pages: 36
DOI: 10.4018/978-1-4666-8603-8.ch018
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Abstract

A thorough understanding of gastrointestinal issues in critical illness is necessary to optimize management of the cardiothoracic patient. Post-operatively, these patients are at increased risk of GI complications due a combination of underlying vascular disease, cardiopulmonary bypass, and low cardiac output, all of which lead to splanchnic hypoperfusion and subsequent damage to the gut mucosa. While GI complications are uncommon, they are associated with a disproportionately high rate of morbidity and mortality. Presence of unexplained fever, leukocytosis, bacteremia, hemodynamic compromise or abdominal pain or distention are concerning and require prompt assessment. Other GI management issues include delivery of adequate nutrition to counteract catabolism and promote wound healing and stress ulcer prophylaxis in patients with risk factors for upper gastrointestinal bleeding.
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Background

Gastrointestinal (GI) complications develop in 1-2% of cardiac surgery patients, but with mortality rates reaching 30% (Rodriguez et al., 2010). This excessively high rate is felt due to both delay in diagnosis, due to non-specific signs and symptoms, and the types of complications, such as GI bleeding and mesenteric ischemia, which already carry a poor prognosis.

Cardiac surgery with or without cardiopulmonary bypass (CPB) increases tissue oxygen demands while also causing a profound reduction in splanchnic perfusion (Fiore et al., 2006; Velissaris et al., 2003). This effect is further exacerbated by low cardiac output and the use of vasoconstrictors (Ohri & Velissaris, 2006). The resultant tissue hypoxia leads to breakdown of typical mucosal functions and potential for atrophy, ulceration, bacterial translocation, the systemic inflammatory response syndrome, and eventually, multi-system organ failure. Risk factors for the development of GI complications are listed in Table 1 (D’Ancona et al., 2003; Filsoufi et al., 2007; Mangi et al., 2005; McSweeney et al., 2004; Rodriguez et al., 2010).

Table 1.
Risk factors for the development of GI complications following cardiac surgery
Pre-OperativeOperativePost-Operative
Age >70 yearsEmergent procedureUse of vasoconstrictors
Poor left ventricular functionDuration of CPBUse of intra-aortic balloon pump
Peripheral vascular diseaseMultiple blood transfusionsMultiple blood transfusions
Chronic renal failureSurgical re-exploration
Anticoagulant useDysrhythmias

Adapted from: Rodriguez et al., Journal of Cardiac Surgery, 2010

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